Cornerstone Multiple Immunization Consent Form

Cornerstone Immunization Consent Form

Vaccine administered by Cornerstone Drug and Gift, Inc. 72 Champlain Street, Rouses Point, NY 12979
- MODERNA COVID VACCINE IS HERE!
- RSV VACCINES ARE ONE TIME ONLY!!! If you have had RSV Vaccine previously, you do NOT require a "Booster"
- You will NOT be able to schedule any of the vaccinations below prior to 2 days out. This is intentional
- There are some insurances that we DO NOT accept (Tricare) and others who we may NOT be a preferred provider with, so for that reason we will ask you to choose your vaccination and schedule your preferred date and time and 2 days will give us time to process your vaccination and confirm it will be covered here and there are no abnormalities (not covered, high copay, deductible, etc...).
- We will contact you if there is a problem, prior to your scheduled appointment.
- IF YOU WOULD LIKE TO SCHEDULE YOUR COVID VACCINE PRIOR TO 2 DAYS FROM NOW, GO BACK TO OUR MAIN PAGE AND CLICK ON FLU/COVID TAB
Please select the Immunization(s) you wish to receive*

RSV (Arexvy) - Ages 75+ (60-74 if you have a chronic condition)Shingles (Shingrix) - Ages 50+Tdap (Tetanus, Diphtheria and Pertussis (whooping cough)) - Ages 12+Pneumococcal (Prevnar or Pneumovax)Covid-19 (Moderna Spikevax 2024-2025 Booster) - Ages 12+
Appointment
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Sex*
Ethnicity*
Race*
Phone Number*
Please enter a valid phone number.
Mother's Maiden Name enter mother's maiden name*
Insurance IDMedicare ID / Last 4 digits of SS#*.
Physician's Name OR*

First NameLast Name
Practice Name
Practice Name
Physician or Practice Phone Number
Please enter a valid phone number.
If you are ages 60-74 and requesting RSV vaccine - Which chronic condition do you have?

Chronic Cardiovascular Disease (eg: Heart failure, coronary artery disease, congenital heart disease , EXCLUDING isolated hypertension)Chronic lung or respiratory disease (eg: COPD, Asthma, Emphysema, interstitial lung disease, cystic fibrosis)End-stage Renal Disease or dependence on Dialysis or other renal replacement therapyDiabetes mellitus complicated by CKD (Chronic kidney disease), neuropathy, retinopathy, or other end-stage organ damage, or requiring treatment with insulin or SGLT-2 inhibitor (Invokana, Farxiga, Jardiance, Steglatro)Neurological or neuromuscular conditions causing impaired airway clearance or respiratory muscle weaknessChronic Liver DiseaseChronic Hematologic Conditions (eg: sickle cell disease)Severe Obesity (BMI > 40kg/m2)Moderate or severe immune compromiseResidence in a nursing home
1. Are you sick today?*

YESNO
2. Do you have allergies to medications, food, a vaccine component or latex?*

YESNO
3.Have you ever had a serious reaction after receiving a vaccination?*

YESNO
4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorders?*

YESNO
5. Do you have cancer, leukemia, HIV, AIDS or any other immune system problem>*

YESNO
6. In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had radiation treatments?*

YESNO
7.Have you had a seizure or brain or other nervous system problem?*

YESNO
8. During the past year, have you received a transfusion of blood or blood products or been given immune (gamma) globulin or an antiviral drug?*

YESNO
9. For Women, Are you pregnant or is there a chance you could become pregnant during the next month?*

YESNON/A
10. Have you received any vaccinations in the past 4 weeks?*

YESNO
Immunization Agreement
I understand that the pharmacy advises me to remain within the pharmacy for at least 20 minutes after the vaccination(s) for observation. I will notify the pharmacy of any adverse events associated with immunization. Permission is herby granted to Cornerstone Drug & Gift to release information to my primary care provider, identified above, regarding any vaccination(s) received today.

NYSIIS Reporting
Our Pharmacy and the New York State Department of Health want to inform you about the Statewide Immunization Information System(IIS) By law, any immunizations given to patients under the age of 19 must be reported into a secure web-based IIS and this electronic system is Called the New York State Immunization Information System (NYSIIS).For patients ages 19 and older, immunizations may be reported to NYSIIS with patient consent. Inclusion of adults will significantly contribute to a fully-developed, population-based database of accurate immunization records, and complete date is essential to developing statewide immunization programs intended to reduce the burden of vaccine preventable disease.

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FOR OFFICE USE ONLY:

(RSV - INFLUENZA - PNEUMOCOCCAL - Tdap - SHINGLES - COVID-19 )
By signing below, I agree to the reporting of my vaccine administration to NYSIIS
Signature*

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Cornerstone Immunization Consent Form